from that usually received when the operator is anxious to overvalue the technic of any particular operation. This method may possibly even exaggerate somewhat the number of recurrences by including some cases of only minimum failure. However, from a comparison of the percentage values obtained in the two series of patients examined by the same methods, it is seen that, in cases of rectocele associated with cystocele, 52 per cent, better results have been obtained with proctopexy than with perineorrhaphy ; while, with rectocele asso¬ ciated with prolapse of the uterus, 75 per cent, improve¬ ment has been obtained with proctopexy over that obtained with the usual perineorrhaphy. The subject of this paper is limited to hernias involving the posterior vaginal wall, which we frequently encounter and recognize under the designation of rectocele, and to the much rarer hernia which is made up of the culdesac of Douglas, with its intestinal contents Fig. 1.-Technic of rectopexy for rectocele: The vagina is separated from the rectum with scissors; the dissection extends well above the line marked for the excision of the vaginal wall.dissecting its way downward between the posterior vaginal wall and the rectum, known as vaginal enterocele or posterior vaginal hernia.The common condition of rectocele is the result of impairment of the function of the pelvic floor (the inability to properly close the vaginal mouth), due to injury in childbirth, thus allowing the vaginal wall to roll downward and outward with the attached rectum. Fig. 2.-Technic of rectopexy for rectocele: The rectopexy suture that is to draw up the rectal pouch to the upper undamaged part of the vagina is in place.This anatomic change in the relation of the parts alters the normal mechanism of defecation, the direction of the fecal current being changed so that the anterior rectal wall and the posterior vaginal wall receive the brunt of the strain and, consequently, protrude more and more until a distinct rectal pouch is formed, which renders complete emptying of the rectum difficult. In cases in which the fasciai support of the vaginal wall has been torn or is attenuated, the rectocele may develop to a large size, with resulting aggravation of symptoms.The usual methods in vogue for curing this hernia are based on the principle of either denudation of the posterior vaginal tissue and approximation of the cut edges or resection of the excess vaginal wall with plica¬ tion of the bowel. The result, so far as the bowel is concerned, is to throw it into folds, which must tend to be smoothed out by the daily passage of fecal masses, especially if constipation exists. In all these opera¬ tions, a perineorrhaphy is relied on to close the vaginal orifice and thus prevent further descensus of the vaginal walls. In the majority of cases with a small or moder¬ ate sized rectocele, these methods are satisfactory in their results, the so-called "interposition" or levator muscle operation being superior to the typical Emmet, in my opinion, so far as the rectocele is conce...
